The Medicaid Team is responsible for the daily billing and follow up of all Medicaid accounts receivable. Daily billing includes timely and thorough review and resolution of all billing edits, errors, and rejections. Timely follow up of all unresolved accounts receivable is required and includes reviewing and appealing all technical denials and escalating clinical appeals to the appropriate area for resolution. Good customer service skills are required to assist patients and internal customers with all concerns and questions.
Required Knowledge & Skills
Education: High School Diploma or GED
Experience: Two years of related experience. Requires working knowledge of specialized practices, equipment, and procedures.
Licenses and Certifications
NONE REQUIRED
Supervision
No supervisory responsibilities.
Qualifications
Two (2) years experience in Medicaid billing and collections in a hospital, clinic, or physician's office setting preferred. Experience working and resolving billing edits, errors and rejections and various claim denials. Customer service skills required as this position involves interaction with patients and various internal departments.
Business -like appearance.
Ability to work closely with others, and function as a team member.
Ability to analyze and prioritize workloads.
Proficiency in spelling, business letter writing, and medical terminology.
Knowledge of electronic documents and spreadsheets. Preferred qualifications includes MS Word and Excel.
Detail oriented.
Assertive without being abrasive.
Good verbal and written communication skills.
Working knowledge of GAMMIS and Alabama Medicaid websites. May also require knowledge of Medicaid CMO websites.
Ability to speak with and follow through with insurance companies to review or obtain pre-certifications, authorizations or referrals.
Working knowledge of ICD diagnosis, HCPCS CPT or procedure codes and how they correlate with payment for all hospital services.
Understanding of billing issues, denial trends and payer claim requirements and communicate this information to various internal departments in order to resolve unpaid or held accounts.
Knowledge of registration data elements is required to correct eligibility and claim errors.
Requirements:
Statement Of Employment Philosophy
Being a part of Tanner Health System is more than a job, it is a promise we make to treat every patient with exceptional service every time they walk through our doors. Service excellence is the foundation of our organizational culture and the expectations we all set for each other, our patients, physicians and our community. All employees agree to abide by a set of service standards. These standards are the promise we make to provide the best care possible, and represent our beliefs, values and who we strive to become. We each commit to making Tanner Health System a great place for our employees to work, for patients to receive care and for physicians to practice medicine.
Functions
Area of Responsibilities
Provides comprehensive customer service functions, including responding to patient inquiries and complaints from all sources in a timely and thorough manner. This function requires interaction with internal departments and physician's offices.
Daily review of all unprocessed billing errors and edits to ensure compliant and timely claims submission. Review and resolution of all claim rejections that are returned from the clearinghouse. Interacts with Team Lead, PFS Director and various internal departments to resolve billing edits.
Conducts daily follow up based on an alpha split within the assigned individual and team work queues. This includes calls to the payer to research and discuss unprocessed accounts. These inquiries require diligence and patience to obtain the details of unresolved accounts receivable. Follow up activities also include researching authorizations, appeals, and denials on the Georgia and Alabama Medicaid and CMO websites.
Reviews and researches all denials posted from remittance advices. Sends coding denials to the HIM Team for review and resolution. Sends charge and billing denials to the Revenue Integrity Team for review and resolution. Technical denials will be thoroughly researched and resolved as soon as the denial is discovered to ensure timely appeal or corrected billing. Reports denial trends to Team Lead or PFS Director to be shared with Payer Provider Representatives and internal committees.
Requires thorough knowledge of Medicaid and Medicaid CMO rules, regulations, policies and procedures related to billing, appeals and follow up of the Medicaid accounts receivables.
Processes and prepares claims related to inpatient Medicare Part A and B billing. This requires diligent research and review to ensure compliant and timely billing for these scenarios.
Reviews and processes retroactive Medicaid cases within expected timeframes.
Identifies accounts that qualify for outlier review, obtains appropriate supporting documentation, and submits complete package to Medicaid. The outlier packet involves review of a checklist to determine all required elements are provided to ensure timely resolution.
Reviews and researches out-of-state Medicaid cases and sends appeals for any denied accounts.
Reviews, processes and scans commercial payer correspondence received. May reassign correspondence to other areas as it pertains to coding, charge or appeal issues.
Recommends and implements process improvements and changes when a process has become redundant or out of date.
Works with the other departments in each facility such as Registration, Physicians offices, Medical Records and Coding Abstracting in making necessary corrections to charges. Recommends process changes which may reduce the frequency of late or lost charges. Ensures timely filing and acceptance of claims for prompt payment. This significantly impacts cash flow and AR days.
Employee performs within the prescribed limits of Tanner Health System's Ethics and Compliance program. Is responsible to detect, observe, and report compliance variances to their immediate supervisor, the Compliance Officer, or the Hotline.
Required Knowledge & Skills
Education: High School Diploma or GED
Experience: Two years of related experience. Requires working knowledge of specialized practices, equipment, and procedures.
Licenses and Certifications
NONE REQUIRED
Supervision
No supervisory responsibilities.
Qualifications
Two (2) years experience in Medicaid billing and collections in a hospital, clinic, or physician's office setting preferred. Experience working and resolving billing edits, errors and rejections and various claim denials. Customer service skills required as this position involves interaction with patients and various internal departments.
Business -like appearance.
Ability to work closely with others, and function as a team member.
Ability to analyze and prioritize workloads.
Proficiency in spelling, business letter writing, and medical terminology.
Knowledge of electronic documents and spreadsheets. Preferred qualifications includes MS Word and Excel.
Detail oriented.
Assertive without being abrasive.
Good verbal and written communication skills.
Working knowledge of GAMMIS and Alabama Medicaid websites. May also require knowledge of Medicaid CMO websites.
Ability to speak with and follow through with insurance companies to review or obtain pre-certifications, authorizations or referrals.
Working knowledge of ICD diagnosis, HCPCS CPT or procedure codes and how they correlate with payment for all hospital services.
Understanding of billing issues, denial trends and payer claim requirements and communicate this information to various internal departments in order to resolve unpaid or held accounts.
Knowledge of registration data elements is required to correct eligibility and claim errors.
Definitions
The Medicaid Team is responsible for the daily billing and follow up of all Medicaid accounts receivable. Daily billing includes timely and thorough review and resolution of all billing edits, errors, and rejections. Timely follow up of all unresolved accounts receivable is required and includes reviewing and appealing all technical denials and escalating clinical appeals to the appropriate area for resolution. Good customer service skills are required to assist patients and internal customers with all concerns and questions.
Position Responsibilities
Contact with Others: Requires frequent contact with many persons at different levels inside and outside of the organization to carry out organization policies and programs and obtain willing acceptance, consent, or action.
Effect of Error: Probable errors not easily detected and may adversely affect external as well as internal relationships and may result in major expenditures for equipment, materials, or procedures detrimental to the patient's welfare or the organization's interest. Work is subject to general review only and requires considerable accuracy and responsibility. Continually works with reports, records, plans, and programs of a major functional area of the organization where integrity is required to safeguard the organization's position. Duties may involve the preparation of data on which the administration bases important decisions and are highly confidential.
People Management Responsibilities
Supervisory Responsibility: Exercises no supervision, work direction, or instruction of other employees or students
Work Environment/Physical Effort
Mental Demands: Work involves a variety of problems in a general field, some of which are complex. Involves some independent judgment to decide what to do to assemble facts, determine variations from standard procedures, or plan other action to be taken to meet general objectives.
Working Conditions: Generally pleasant working conditions/normal office environment.
Working Conditions Aspects for Immunizations
Performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps (needles): No
Directly works with Patients less than 12 months of age: No
Physical Effort: Moderate physical effort - Lifts, carries, or handles lightweight (1 to 25 lbs.) materials or equipment for about half of the day. Very occasional physical effort with medium weight objects (25- 60 lbs.). Office or laboratory work requires close visual effort and concentration more than half of day. Works in reaching or strained positions for less than half of day.
Physical Aspects
Bending: Not required
Typing: Constant = 67% - 100% of the time.
Hearing: Constant = 67% - 100% of the time.
Visual: Constant = 67% - 100% of the time.
Speaking: Constant = 67% - 100% of the time.
Standing: Occasional = 1% - 33% of the time
Walking: Occasional = 1% - 33% of the time
Lifting up to 25 lbs.: Occasional = 1% - 33% of the time
Lifting 25 to 60 lbs.: Not required
Lifting over 60 lbs.: Not required
Carrying: Occasional = 1% - 33% of the time
Climbing: Not required
Kneeling: Not required
Tasting: Not required
Smelling: Not required
Manual Dexterity - picking, pinching with fingers etc.: Occasional = 1% - 33% of the time
Feeling (Touch) - determining temperature, texture, by touching: Not required
Reaching - above shoulder: Not required
Reaching - below shoulder: Occasional = 1% - 33% of the time
Color Vision: Occasional = 1% - 33% of the time
Balancing: Not required
Crawling: Not required
Running - in response to an emergency: Not required
Handling - seizing, holding, grasping: Occasional = 1% - 33% of the time
Squatting: Not required
Driving - Utility vehicles such as golf carts, Gators, ATV, riding lawnmowers, skid steer, aerial lift: Not required
Driving - Class C vehicles: Not required
Driving - CDL class vehicles: Not required
N95 Respirator usage (PPE): Not required
Hazmat suit usage (PPE): Not required
Pushing/Pulling - up to 25 lbs.: Not required
Pushing/Pulling - 25 to 60 lbs.: Not required
Pushing/Pulling - over 60 lbs. : Not required